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Pediatrik 

1) (OBQ12.58) Which of the following most accuratel descri!es the cause of osteo"etrosis#

$e%iew &o"ic 

Q' **18

1. ecreased e+"ression of t"e ' collagen

,- (/2*0)

2. ecreased mineraliation of osteoid matri+ 

- (1*/2*0)

,. 3oss4of4function of 6 al"ha "rotein gene 

- (1**/2*0)

*. 3oss4of4function of car!onic anhdrase '' gene

82- (2,0/2*0)

5. 7utation of $, 

*- (0/2*0)

P$99$$9 $96PO:69 ▶ *

Osteo"etrosis is characteried ! defecti%e osteoclastic resor"tion of immature !one caused

 ! a loss4of4function mutation in the car!onic anhdrase '' gene.

;ar!onic anhdrase '' is an enme that con%erts car!on dio+ide and water into <= and

 !icar!onate. &he "rotons created are then trans"orted across the ruffled !order of osteoclasts>

leading to acidification and demineraliation of !one matri+. &here are ? and ?$ forms of

osteo"etrosis> with the ?$ form usuall !eing fatal in the first few ears of life.

6cwart et al. "resent a case re"ort of an infant with osteo"etrosis and no famil histor.

iagnosis was made ! generalied increased radiological !one densit and ! a !one !io"s

showing "ersistence of calcified cartilage. 7easurement of his erthrocte car!onic

anhdrase acti%it re%ealed a deficienc of ;? ''.

'llustration ? shows ;? '' con%erting water and car!on dio+ide to !icar!onate and "rotonswithin an osteoclast. &he "rotons are then shuttled across the ruffled !order where !one is

resor!ed.

'ncorrect ?nswers

?nswer 1 Osteogenesis im"erfecta is associated with a decrease in t"e ' collagen (;O3

1?1 and ;O3 1?2 genes)

?nswer 2 $ickets is associated with a defect in mineraliation of osteoid matri+ caused !

inade@uate calcium and "hos"hate

?nswer , i!rous ds"lasia is associated with a 6 al"ha "rotein mutation

?nswer 5 ?chondro"lasia is associated with a mutation of $, (fi!ro!last growth factor

rece"tor ,> on chromosome *P)

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2). (OBQ.*2) ? 124ear4old !o with sickle cell anemia com"lains of 2* hours of "ain in

the right thigh. <e denies an traumatic inAur. &he right leg has tenderness with "al"ation of

the mid4thigh. &he "atients tem"erature is 1.2 degrees > and 96$ is *5. $adiogra"hs of

the femur are unremarka!le. ? radionuclide !one scan demonstrates a!normal u"take in the

mid4femur. ? radionuclide !one marrow scan demonstrates decreased u"take within the

marrow. Which of the following is the !est ste" in management# $e%iew &o"ic 

Q' 15,

1. 6m"tomatic care for his "ain with :WB crutches> intra%enous hdration> and

consultation with hematolog

8- (212/,1)

2. 6teroid inAection of the @uadrice"s 

- (/,1)

,. &wo weeks of an oral ce"halos"orin and follow4u" radiogra"hs 

1- (*/,1)

*. Bone !io"s for culture and intra%enous anti!iotics 

10- (58/,1)

5. 6urgical de!ridement> culture> and intra%enous anti!iotics 

12- (,/,1)

P$99$$9 $96PO:69 ▶ 1

6ickle cell crises resulting in !one infarcts can !e difficult to differentiate from acute

osteomelitis with "hsical e+am and "lain radiogra"hs alone. &his child is undergoing a

 !one infarct as confirmed ! his radionuclide scans.

6kaggs et al re%iewed C0 cases of acute e+tremit "ain in sickle cell "atients. $adionuclide

 !one marrow and !one scan was used to differentiate osteomelitis from !one infarct. our

cases of infection were diagnosed ! normal u"take on the !one marrow scan and a!normal

u"take on the !one scan. &hese cases were confirmed osteomelitis ! "ositi%e culture.

6e%ent cases were diagnosed as !one infarct ! decreased u"take on the !one marrow scanand a!normal u"take !one scan.

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;ham!ers et al re%iewed the charts of 2 known sickle cell "atients. ourteen "atients had

an e"isode of osteomelitis or se"tic arthritis. $adiogra"hs and !one scans were not hel"ful

in differentiating infection from an acute !one infarct. 6almonella was the most fre@uent

organism cultured from the osteomelitis cases. &he authors recommend !one as"iration or

 !io"s in an sickle cell "atient with e+tremit "ain> swelling> and a fe%er greater than ,8.2degrees ;.

3) (OBQ5.1*) ? 1* ear4old girl has chronic foot "ain which has failed to res"ond to

 "re%ious surgical coalition resection and soft tissue inter"osition. ? radiogra"h of her foot is

shown in igure ?. ? ;& scan demonstrates a talocalcaneal coalition with almost com"lete

in%ol%ement of the su!talar Aoint. What is the treatment of choice# $e%iew &o"ic 

'D$96 ?

Q' 12

1. re%ision coalition resection and e+tensor digitorum !re%is inter"osition

12- (82/58)

2. re%ision coalition resection and fat inter"osition 

C- (**/58)

,. ti!iotalocalcaneal arthrodesis 

5- (,/58)

*. talona%icular arthrodesis 

*- (2C/58)

5. tri"le arthrodesis

C1- (*C/58)

P$99$$9 $96PO:69 ▶ 5

or sm"tomatic coalition !efore degenerati%e changes ha%e occurred> resection is the usual

treatmentE howe%er> this is not indicated if the "atient has failed "re%ious coalition resection

surger> and has greater than 5- in%ol%ement of the "osterior facet of the su!talar Aoint.

&ri"le arthrodesis in%ol%es fusion of the su!talar> calcaneocu!oid> and talona%icular Aoints

and is the most effecti%e "rocedure for fi+ed hindfoot and forefoot deformities. 6u!talarfusion can !e "erformed in select cases with no significant hindfoot deformit. &his

 "rocedure is contraindicated in oung children (1412 ears) !ecause of the limitation it "uts

on foot growth. Wilde et al found fair or "oor results in all ten feet with "reo"erati%e ;&

scans showing an area of relati%e coalition to !e F5- and heel %algus F 1 degrees.

6cranton re"orted consistentl successful resections of talocalcaneal coalitions if the coalition

was less than one4half of the surface area of the talocalcaneal Aoint and there was no

degenerati%e arthritic changes in the talona%icular Aoint.

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*) (OBQ*.C*) ?ll of the following are clinical features of neurofi!romatosis t"e ' (:4')

9G;9P&# $e%iew &o"ic 

Q' 11C0

1. freckling in the a+illae

*- (1/2C2)

2. o"tic glioma 

11- (,/2C2)

,. 2 or more 3isch nodules 

,- (8/2C2)

*. tali"es e@uinus

81- (22/2C2)

5. cafe au lait s"ots 

1- (,/2C2)

P$99$$9 $96PO:69 ▶ *

 :41 is an autosomal dominant disorder> with a""ro+imatel 5- of cases due to a new

mutation. 't is the most common genetic disorder caused ! a new mutation of a single gene.

&he entit is @uite common> affecting 1 in *> and is one of the most common dominantl

inherited gene disorders in humans. ?ccording to the :'< ;onsensus e%elo"ment

;onference 6tatement (108C) the diagnostic criteria for :41 are met in an indi%idual if twoor more of the following are found 1) 6i+ or more cafH4au4lait macules o%er 5 mm in greatest

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diameter in "re"u!ertal indi%iduals and o%er 15 mm in greatest diameter in "ost"u!ertal

indi%iduals. 2) &wo or more neurofi!romas of an t"e or one "le+iform neurofi!roma. ,)

reckling in the a+illar or inguinal region. *) O"tic glioma. 5) &wo or more 3isch nodules

(iris hamartomas). )

? distincti%e osseous lesion such as s"henoid ds"lasia or thinning of long !one corte+ with

or without "seudarthrosis. C) ? first4degree relati%e ("arent> si!ling> or offs"ring) with :41 ! the a!o%e criteria. ?ccording to the ;rawford article> common ortho"aedic manifestations

are Is"inal deformit> congenital ti!ial ds"lasia (congenital anterolateral ti!ia !owing and

 "seudarthrosis)> and disorders of e+cessi%e !one and soft4tissue growthI.

5 ) (OBQ5.120) igure ? shows a lateral radiogra"h of an 04month olds dorsifle+ed foot.

What is the first line treatment for this condition# $e%iew &o"ic 

'D$96 ?

Q' 115

1. O!ser%ation 

8- (5*/*)

2. 6erial casting

*C- (,11/*)

,. 7ani"ulation under anesthesia followed ! a single casting 

1- (8/*)

*. 6urgical re4alignment 

2- (1/*)

5. 6erial mani"ulation and casting followed ! surgical release and talona%icular

reduction with "inning 

*1- (2C5/*)

P$99$$9 $96PO:69 ▶ 2

&he radiogra"hs show hindfoot "arallelism !etween the talus and calcaneus which is

characteristic of congenital tali"es e@uino%arus> also known as clu!foot. &his @uestion

em"hasies the im"ortance of the talocalcaneal angle. rom a testing "ers"ecti%e> it is

im"ortant to !e a!le to differentiate clu!foot from congenital %ertical talus (;J&) on

radiogra"hs. Jertical talus will not show the "arallelism !etween the talus and calcaneus seen

with clu!foot and the na%icular (which is not ossified in infants) will not !e aligned with the

talus e%en on attem"ts to reduce with "lantarfle+ion. 7ears angle and the talocalcaneal

angle are shown for clu!foot and %ertical talus in 'llustration ? and B res"ecti%el.

$oe> et al. stated that all radiogra"hs of the foot should simulate weight !earing. &he two

most commonl used measurements are the lateral and ?P talocalcaneal angles> which

dis"la "arallelism.

3aa%eg et al re%iewed the long term treatment of congenital clu!foot and found thatfunctional results were satisfactor in !oth a""earance and function in 88.5- of 1* clu!feet.

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6) (OBQ1.1) Which of the following must !e done whene%er a non4am!ulator infant

 "resents to the 9$ with a dia"hseal long !one fracture# $e%iew &o"ic 

Q' ,80

1. 'mmediate consultation with child "rotecti%e ser%ices and "ossi!le admission to the

hos"ital

00- (1C8/180)

2. Order serum %itamin le%els 

- (,/180)

,. Order serum calcium and "hos"horus le%els 

- (/180)

*. 7$' of the cer%ical s"ine 

- (/180)

5. Perform genetic testing for ;O314?1 and ;O314?2 

- (5/180)

P$99$$9 $96PO:69 ▶ 1

9ach of the answers could !e "erformed in this scenario as "art of a diagnostic e%aluation.

<owe%er> missing a case of child a!use could result in further a!use of the child or e%en

death> making this the most im"ortant issue to address.

Banaskiewic et al "erformed a retros"ecti%e re%iew o%er a fi%e ear "eriod on children K 1

ear of age who "resented to the 9$ with a fracture. &he found that 28- of the time> a!use

was underestimated at the time of e%aluation. &he recommend admitting all "atients in thisage grou" with an fracture and consulting child "rotection ser%ices.

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7) (OBQ.C5) Plantar fle+ion of the first ra is the initial deformit seen in which

condition# $e%iew &o"ic 

Q' 18

1. O!li@ue talus

2- (1C/825)

2. Lohlers disease 

2- (1C/825)

,. ;harcot47arie4&ooth

0- (C*/825)

*. ;alcaneo%algus foot 

*- (,1/825)

5. Mu%enile hallu+ %algus 

1- (12/825)

P$99$$9 $96PO:69 ▶ ,

;harcot47arie4&ooth (;7&) disease is a hereditar motor sensor neuro"ath. &hese "atients

often de%elo" a "es ca%o%arus deformit ('llustration ?) with the intial stage !eing "lantar

fle+ion of the 1st ra.

? weakened ti!ialis anterior / "eroneus !re%is is o%er"owered ! a stronger "eroneus longus /

 "osterior ti!ialis and results in a "lantar fle+ed first metatarsal and "ronated forefoot as

descri!ed in the article ! 7osca. <indfoot %arus deformit de%elo"s secondaril. ?s the

deformities !ecome more fi+ed> an e@uinus deformit can also de%elo".

;oleman !lock testing as descri!ed in ;O$$ from 10CC can hel" determine if the hindfoot

%arus deformit is fi+ed or fle+i!le. <indfoot fle+i!ilit is noted ! "lacing the lateral foot on

a !lock to remo%e the "lantar fle+ed first ra from contri!uting to the deformit and

o!ser%ing the hindfoot mo%ing to a more neutral "osition.

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8) (OBQ0.1*1) ? ,4ear and 4month old child fell while "laing with friends 2 hours ago

and has a%oided !earing weight on the right leg since that time. &he child is afe!rile and

e+am re%eals tenderness along the distal ti!ial shaft with no significant swelling. $adiogra"hs

are shown in igure ? and B. What is the most a""ro"riate treatment# $e%iew &o"ic 

'D$96 ? B

Q' 205*

1. 7$' of the ti!ia 

1- (8/1,18)

2. ?s"iration of the ti!ia 

- (,/1,18)

,. $eferral to child ser%ices 

,- (,,/1,18)

*. 3ong leg cast a""lication

0- (12*/1,18)

5. 6erum %itamin > calcium> and "hos"hate le%els

1- (C/1,18)

P$99$$9 $96PO:69 ▶ *

&he clinical "resentation and radiogra"hs are consistent with a toddlers fracture of the ti!ia

and the ne+t ste" in management includes long leg cast a""lication.

?s descri!ed ! 7ellick et al this scenario is classic for the toddlers fractureE a toddler4aged

child with a%oidance of weight!earing after a fall. &he radiogra"hs demonstrate a non4

dis"laced s"iral fracture of the distal ti!ial shaft. &here are no signs/sm"toms of infection> so7$' and as"iration are not a""ro"riate. 7eta!olic work4u" is not warranted for this common

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t"e of fracture. ;hild a!use should !e sus"ected with long !one fractures of the lower

e+tremit in child who are not et am!ulator (not this case).

9) (OBQ5.1,5) ? 14ear4old !o "resents with medial foot "ain that is se%ere enough that

it limits his dail acti%ities such as walking to school. Phsical e+am shows tenderness in the

medial forefoot , cm anterior and inferior to the medial malleolus. ? radiogra"h is shown in

igure ?. :ono"erati%e treatment including orthotics and cast immo!iliation was attem"ted

for three months without success. What is the most a""ro"riate ne+t ste" in treatment#

$e%iew &o"ic 

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'D$96 ?

Q' 121

1.  :o treatment needed4return to class 

1- (1*/10,5)

2. ;ontinue serial casting 

1- (1,/10,5)

,. 9+cision of the medial "rominence of the na%icular> including the snchondrosis

05- (18,/10,5)

*. O$' of the na%icular non4union 

,- (51/10,5)

5. Bone stimulator for the na%icular non4union- (C/10,5)

P$99$$9 $96PO:69 ▶ ,

&his "atient has a "ainful accessor na%icular that has failed conser%ati%e treatment. 9+cision

of the medial "rominence of the na%icular is indicated as a second line of treatment.

&he accessor na%icular is a normal %ariant seen in u" to 12- of the "o"ulation. $e"etiti%e

microtrauma at the le%el of the snchondrosis ma lead to medial foot "ain. 'f non4o"erati%e

management fails> e+cision of the accessor na%icular is indicated. Often> ad%ancement of the

 "osterior ti!ial tendon is com"leted with accessor na%icular e+cision (Lidner "rocedure).

&he theor is that this hel"s restore the "ull of the tendon and "re%ents medial arch sag.

Lo"" et al. retros"ecti%el re%iewed sm"tomatic "atients treated with accessor na%icular

e+cision and anatomic re"air of the "osterior ti!ialis tendon. &hirteen of 1* "atients were

 "ain4free. :o "atients had acti%it limitations and all were satisfied with the outcome.

Bennett et al. retros"ecti%el re%iewed sm"tomatic "atients treated with accessor na%icular

e+cision and anatomic re"air of the "osterior ti!ialis tendon. ood and e+cellent results were

o!tained in 0- of "atients.

igure ? shows an ?P radiogra"h of the foot that demonstrates an accessor os of thena%icular.

'ncorrect ?nswers

?nswers 1> 2 i%en that this "atient has e+hausted conser%ati%e measures> surgical

inter%ention is the ne+t !est ste".

?nswers *> 5 &his is not a na%icular fracture.

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10 ) (OBQ0.1C8) ? 04ear4old !o fell off of a swing set and inAured his left el!ow.

$adiogra"hs are shown in igures ? and B. O"en reduction and internal fi+ation of this

fracture is indicated secondar to which of the following $e%iew &o"ic 

'D$96 ? B

Q' 2001

1. is"lacement of greater than 5 mm 

5- (,/CC)

2. ?n incarcerated fragment in the ulnohumeral Aoint

8- (0/CC)

,. 2= %algus la+it seen with manual stressing

1- (/CC)

*. &o "re%ent cu!itus %algus deformit 

,- (10/CC)

5. <igh risk of sm"tomatic non4union of fragment 

5- (,/CC)

P$99$$9 $96PO:69 ▶ 2

7edial e"icondle a%ulsion fractures can !e treated with o"en reduction and internal fi+ation

when the fractured fragment is incarcerated in the ulnohumeral Aoint or if there is significant

ulnar ner%e dsfunction. igures ? and B show a dis"laced medial e"icondle fracture that is

incarcerated in the ulnohumeral Aoint> thus re@uiring O$'.

3ee et al studied 25 "ediatric "atients who had undergone O$' of a medial e"icondle

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fracture and found no correlation !etween surgical outcome and inAur mechanism>

dis"lacement> inter%al from inAur to surger> dislocation> fi+ation method> or duration of

immo!iliation. ?ll "atients in this stud had good to e+cellent outcomes.

arsetti et al com"ared "ediatric "atients with medial e"icondle fractures with dis"lacement

F 5mm who recei%ed a long arm cast without reduction> O$'> and e+cision. &he found nodifference in long term results !etween "atients treated with O$' and those who recei%ed

non4o" treatment> while those treated with e+cision had "oor long term results.

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11) (OBQ1,.2,) Nou are the team "hsician for a collegiate foot!all team and recei%e

weekl inAur re"orts from the athletic trainer. ?ll "laers with sickle4cell trait are listed at

the !ottom to remind all on4field "ersonnel that the ma need which of the following# 

$e%iew &o"ic 

Q' *58

1. O+gen su""lementation and oral or 'J hdration

0*- (211*/22*5)

2. ?dditonal laers of warm clothes

1- (2*/22*5)

,. 'ncreased "ain medication 

- (C/22*5)

*. ?%oidance of non4steroidal anti4inflammator medicines

2- (51/22*5)

5. as of rest due to increased Aoint "ain 

2- (*/22*5)

P$99$$9 $96PO:69 ▶ 1

Plaers with a !lood test indicating the "resence of sickle4cell trait (6;&) are at risk for

e+ertional sickling colla"se which res"onds initiall to rest> hdration and o+gen.

6;& is not a disease !ut a condition> resulting from inheritance of one gene for sickle

hemoglo!in (6) and one gene for normal hemoglo!in (?).

&he %ital concern is e+ertional sickling colla"se> which can !e fatal> occurs in a %ariet of

s"orts> and is a leading cause of death in college foot!all.

?ccording to the re%iew ! 9ichner> sickling colla"se is an intensit4associated sndrome

that differs from the other common causes of colla"se. &he !est a""roach in college foot!all

ma !e tailored "recautions to "re%ent sickling colla"se and ena!le athletes with 6;& to

thri%e. Other clinical concerns in 6;& are com"artment sndromes and lum!ar monecrosis>

s"lenic infarction> gross hematuria> h"osthenuria> and %enous throm!oem!olism.

Lark et al. re%iewed all cases of sudden death occurring among 2 million enlisted recruits

during !asic training in the D.6. ?rmed orces from 10CC to 1081. &he concluded that

Irecruits in !asic training with the sickle4cell trait ha%e a su!stantiall increased> age4

de"endent risk of e+ercise4related sudden death une+"lained ! an known "ree+isting

causeI.

'ncorrect $es"onses

2. no research to su""ort need for warmer clothes and cases occur ear round.

,4*. these are t"ical of sickle cell disease> not 6;&.

5. im"ortant in "atients with renal im"airment which is not t"icall seen in 6;&.

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12 ) (OBQ5.2,) ? ,4month4old !o has worsening !ilateral !owleg deformities> and

radiogra"hs de"icting 3angenskiold stage '' are shown in igure ?. &he most a""ro"riate

initial management should consist of which of the following#  $e%iew &o"ic 

'D$96 ?

Q'

1. O!ser%ation

2- (1C*/*)

2. Bracing with knee4ankle4foot orthoses

5C- (,8/*)

,. Bracing with ankle4foot orthoses

*- (2C/*)

*. Pro+imal ti!ia/fi!ula %algus osteotom with !ar resection 

5- (,,/*)

5. Pro+imal ti!ia/fi!ula %algus osteotom with hemie"i"hsiodesis 

C- (*/*)

P$99$$9 $96PO:69 ▶ 2

'nitial management of infantile Blounts disease in children less than , ears old consists of

full time !racing with a knee4ankle4foot orthosis.

'nfantile Blounts disease is "athologic cause of genu %arum in children less than , ears of

age. $adiogra"hicall> a widened and irregular medial "hseal line and an irregularl ossified

and mediall slo"ed e"i"hsis are seen. 'nitial treatment is non4o"erati%e in children less than

, ears of age. O"erati%e management in children older than , is considered if non4o"erati%e

management has failed> or in 3angenskiold classes J and J'> where there is a congenital !ar

across the "hsis. When osteotom is re@uired> o%ercorrection to at least 5 degrees of %algus

should !e done.

$ichards et. al. re"orted successful outcomes following !racing for an a%erage of 0 months in

 "atients , ears and ounger with 3angenskiold stage '' or less. Patients with !ilateral disease

more commonl re@uired osteotom.

igure ? shows !ilateral infantile Blounts disease> with %arus angulation of the ti!ial

meta"hsis and !eaking of the medial meta"hsis.

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13 ) (OBQ8.15) 'n "atients older than 124months of age with de%elo"mental ds"lasia ofthe hi"> all of the following "hsical e+am findings are likel "resent 9G;9P&# $e%iew

&o"ic 

Q' 5,

1. 3imited hi" a!duction 

,- (2/C80)

2. Positi%e Ortolani maneu%er

8,- (5C/C80)

,. ?!normal leg lengths on aleai testing

2- (18/C80)

*. &rendelen!urg gait 

C- (5C/C80)

5. Pel%ic o!li@uit

5- (,/C80)

P$99$$9 $96PO:69 ▶ 2

&here are man e+am maneu%ers which are used in the diagnosis of de%elo"mental ds"lasia

of the hi" (<). 9+am findings differ !ased on the age of the "atient.

Jitale et al em"hasie that "hsical e+am findings associated with < in a child older than

124months can !e different than those seen in the new!orn. 6"ecificall> limited hi"

a!duction> a "ositi%e aleai test> a "ositi%e &rendelen!urg gait> and asmmetr of hi"

a!duction are all useful e+ams tests that are likel to !e "ositi%e. &he Barlow and Ortolani

maneu%ers are of limited use in older children (F months) !ecause the soft tissues a!out the

hi" tighten.

'llustration J demonstrate how the Barlow and Ortolani test are "erformed.

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14 ) (OBQ1.25) Which of the following "ediatric congenital disorders is caused ! a

glcine su!stitution in the "rocollagen molecule# $e%iew &o"ic 

Q' ,,1

1. 6cur% 

8- (1C/1,*)

2. Osteogenesis im"erfecta

8- (108/1,*)

,. i!rous ds"lasia 

5- (0/1,*)

*. iastro"hic ds"lasia

*- (*0/1,*)

5. Ochronosis (alka"tonuria) 

,- (,8/1,*)

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Osteogenesis im"erfecta (O') is caused ! a defect in &"e ' collagen (;O31?1 and

;O31?2) that causes a!normal cross4linking %ia a glcine su!stitution in the "rocollagen

molecule. &his defect leads to decreased collagen secretion> !one fragilit> wormian !ones>

short stature> scoliosis> tooth defects> hearing defects> and ligamentous la+it.

&he article ! ;ole e+"lains that O' includes a wide s"ectrum of disease and has %arious

inheritance "atterns (autosomal dominant or autosomal recessi%e). i!rous ds"lasia is

caused ! a germ line defect in the sa "rotein. 6cur% is caused ! a %itamin ; deficienc

that causes a decrease in chondroitin sulfate snthesis and su!se@uent defect in intracellular

hdro+lation of collagen "e"tides. iastro"hic ds"lasia is caused ! a mutation of a gene

coding for a sulfate trans"ort "rotein. Ochronosis (alka"tonuria) is caused ! a defect in the

homogentisic acid o+idase sstem.

15) (OBQ.11,) What is the most common com"lication following surgical fi+ation for the

fracture shown in igure ? in an 84ear4old !o# $e%iew &o"ic 

'D$96 ?

Q' 200

1. ;o+a %alga

5- (12/25C)

2. ;hondrolsis 

*- (1/25C)

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,. 6tiffness 

*- (0/25C)

*. ;linicall significant lim! length discre"anc 

5- (1,/25C)

5. ?%ascular necrosis

82- (212/25C)

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&he radiogra"h demonstrates a "ediatric !asicer%ical femoral neck fracture. emoral neck

fractures in the "ediatric "o"ulation are associated with a high rate of osteonecrosis. &he are

di%ided into e"i"hseal> transcer%ical> !asicer%ical and intertrochanteric. racture

dis"lacement> age o%er ten ears and an e"i"hseal or transcer%ical fracture "attern are risk

factors for ?J:.

7oon et al found the rates of ?J: were as follows el!et t"e ',8-> ''28-> '''18->

and 'J5-> where '9"i"hseal> ''&ranscer%ical> '''Basicer%ical> 'J'ntertrochanteric.

<ughes et al discussed se%eral com"lications. ;o+a %ara> not co+a %alga> occurs a!out 24

,- of the time and is more common in fractures treated nono"erati%el.

'ncorrect ?nswers

;hondrolis has !een re"orted s"oradicall> !ut is alwas found concomitantl with ?J:.

6tiffness is not commonl seen after surgical fi+ation. Premature "hseal closure can occur

with or without surger !ut !ecause the femoral head e"i"hsis is onl res"onsi!le for 1,-

of the ultimate length of the femur> growth distur!ances rarel result in lim! length

discre"ancies e+ceeding 2 cm. 'f dis"laced> the fracture re@uires o"en reduction> hematoma

e%acuation and internal fi+ation with "ins. Whether or not the "ins should cross the "hsis is

still su!Aect to de!ate.

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Waters studied the natural histor of !rachial "le+us "als and the effects of treatment

including microsurgical re"air> tendon transfer> and derotational osteotom.

6mith et al e%aluated 1C "atients to determine "rognosticators for reco%er of function in

 !rachial "le+o"ath. &he found that "rolonged neurological reco%er or a greater le%el ofinitial inAur were each associated with worse long4term shoulder function.

17 ) (OBQ.0) ? 1,4month4old !o has shortening and deformit of the right leg. ?

clinical "hotogra"h and radiogra"h are "ro%ided in igures ? and B. Which of the following

findings are indicati%e of a good outcome with a ti!iotalar 6me am"utation#  $e%iew

&o"ic 

'D$96 ? B

Q' 21

1. ,5 degree fle+ion contracture 

2- (8/5,2)

2. ?!sence of ti!iofi!ular snostosis 

12- (5/5,2)

,. Bilateral in%ol%ement 

- (2/5,2)

*. ull functional @uadrice"s strength

85- (*5/5,2)

5. amil histor of ti!ial hemimelia

1- (*/5,2)

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&he clinical scenario and images demonstrate ti!ial hemimelia. ?n am"utation !elow the

knee has greater likelihood of success if there is a functional @uadrice"s and no fle+ion

contracture of the knee. Otherwise> a knee disarticulation ma !e necessar.

Lalamchi et al re%iew 2* cases of ti!ial hemimelia to esta!lish a classification scheme. &"e '

is total a!sence of the ti!ia. &"e '' is distal a!sence of the ti!ia. &"e ''' is distal deficienc

with ti!iofi!ular diastasis. ?ssessment of the @uadrice"s function and degree of fle+ion

contracture is crucial to following the a""ro"riate treatment o"tion.

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18) (OBQ.255) ? 54ear4old !o has a histor of !eing treated with the Ponseti techni@ue

for a unilateral clu!foot. What muscle most commonl causes a dnamic deformit in the

swing "hase of gait following Ponseti casting# $e%iew &o"ic 

Q' 2

1. &i!ialis Posterior  

12- (*,/,*C)

2. &i!ialis ?nterior

C*- (258/,*C)

,. astrocnemius 

8- (2C/,*C)

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*. Peroneus 3ongus

5- (1/,*C)

5. Peroneus Bre%is 

- (1/,*C)

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'n clu!foot "atients older than 12 to 18 months> a dnamic swing "hase su"ination deformit

ma de%elo" as a result of medial o%er"ull of the anterior ti!ialis tendon. 'ncom"lete

reduction of the na%icular onto the talar head results in changing the anterior ti!ialis muscle

from "redominatel a strong dorsifle+ing to a strong su"inating force. 'f uncorrected> this

ma lead to dnamic deformit during the swing "hase of gait.

&he stud ! '""olito et al found that at long term followu" children treated with Ponsetis

mani"ulation techni@ue and cast immo!iliation followed ! an o"en heel4cord lengthening

had !etter outcomes than those that underwent Ponseti techni@ue and e+tensi%e "osteromedialrelease.

&he stud ! Luo et al re%iewed C1 feet who had residual dnamic clu!foot deformit that

underwent either s"lit or com"lete anterior ti!ial tendon transfer. Both treatments resulted in

increased dorsifle+ion and e%ersion $O7> e%ersion strength> and correction of forefoot

adduction and su"ination. &he concluded there was little clinical signficance !etween the

two surgical a""roaches.

&he article ! Ponseti descri!es his method for the treatment of congenital clu!foot

deformit. &he ca%us deformit is corrected ! su"ination of the fore "art of the foot. &he

%arus deformit of the hindfoot is corrected with dis"lacement or lateral rotation of the

na%icular> together with the cu!oid and the anterior as"ect of the calcaneus> without "ronation

of the foot. &he foot "osition is maintained in a toe4to4groin "laster cast with the knee fle+ed

0 degrees and the foot in ma+imum e+ternal rotation. &he e@uinus is corrected last> !

dorsifle+ion of the foot with the heel in %algus angulation. ? tendo4achilles tenotom can

facilitate correction of e@uinus. &o decrease the risk of recurrence> a enis Brown s"lint is

utilied full time for se%eral months and then con%erted to "art4time wear.

19) (OBQ5.2*1) Which of the following inAuries is associated with the highest risk of

mor!idit and mortalit in a "ediatric trauma "atient#  $e%iew &o"ic 

Q' 112C

1. Pel%ic fracture 

,*- (258/C8)

2. 6ca"ula fracture 

12- (0,/C8)

,. 6"ine fracture

5,- (*C/C8)

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*. emur fracture 

1- (0/C8)

5. &i!ia fracture 

- (/C8)

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Buckle et al re%iewed 85 "ediatric trauma "atients who sustained 05, fractures and

dislocations to determine the relationshi" !etween skeletal inAur and trauma score> inAur

se%erit score> length of hos"ital sta> hos"ital charges> and mortalit. &he femur was the

most commonl fractured !one> and o%erall mortalit was ,- in the grou" studied. &he

trauma "atients with associated sca"ula or "el%ic fractures had an 11- mortalit rate>

whereas those "atients with s"ine fractures had a 1- mortalit rate. emur and ti!ia

fractures had a mortalit rate of 2- and 1- res"ecti%el. &he authors concluded that central

musculoskeletal inAuries (s"ine> cla%icle/sca"ula> and "el%is) were associated with the longest

hos"ital stas and intensi%e care unit admissions> as well as the highest 'nAur 6e%erit6cores> hos"ital charges> and mortalit rates. &e"as et al re%iewed the records of *>*

children with traumatic head inAuries> and com"ared them to head inAuries re"orted from an

adult trauma registr. &he found that o%erall children ha%e a lower mortalit than adults> and

that ;:6 inAur is the "redominant and most common cause of "ediatric traumatic death.

 20 ) (OBQ12.,0) ? 284ear4old ?frican4?merican male with a histor of 6ickle ;ell

isease com"lains of "rogressi%e left hi" "ain for the "ast two ears. <e denies an causati%e

inAuries. <is images are shown in igures ? and B. Which of the following mechanisms is

most likel res"onsi!le for his sm"toms# $e%iew &o"ic 

'D$96 ? B

Q' *,00

1. Blood disorder due to a!normal hemoglo!in 6 alleles

01- (218/2,0)

2. Progressi%e sli""age of "hsis though the h"ertro"hic one

1- (25/2,0)

,. Osteomelitis most likel due to 6almonella s"ecies 

5- (112/2,0)

*. ?ccumulation of glcosaminoglcan !reakdown "roducts

2- (*5/2,0)

5. ;O35?1 or ;O35?2 mutation

1- (10/2,0)

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&he clinical "resentation and images are most consistent with left hi" osteonecrosis as a result

of coagulation and %ascular occlusion caused ! sickle cell anemia.

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6ickle cell disease is a genetic disorder of hemoglo!in snthesis characteried ! 2 a!normal

hemoglo!in 6 alleles. Dnder low o+gen conditions the affected !lood cells !ecome Isickle

sha"edI and una!le to "ass through %essels. &his results in %ascular occlusion that ma ha%e a

%ariet of clinical conse@uences de"ending on the !od "art affected.

<ernigou et al. re%iew the natural histor of sm"tomatic osteonecrosis in adults with sicklecell disease. Once sm"tomatic > osteonecrosis of the hi" in sickle cell disease has a high

likelihood of "rogressing and leading to femoral head colla"se. eterioration can !e ra"id

and in most "atients o"erati%e inter%ention is necessar to "re%ent further colla"se or

alle%iate intracta!le "ain.

7ont et al. "erformed a literature re%iew on the natural histor of untreated asm"tomatic

osteonecrosis of the femoral head. &heir findings su""orted that asm"tomatic osteonecrosis

had a high "re%alence of "rogression to sm"tomatic femoral head colla"se. 6mall> mediall

located lesions had a low rate of "rogression> while medium to large sied osteonecrotic

lesions did "rogress in a su!stantial num!er of "atients. &he recommended consideration of

 Aoint4"reser%ing surgical treatment in asm"tomatic "atients with a medium4sied or large>laterall located lesion.

igure ? shows an ?P "el%is with left hi" osteonecrosis. igure B shows a &2 coronal 7$'

with left hi" osteonecrosis. 'llustration ? shows an e+am"le of a hemoglo!in molecule which

has !ecome Isickle sha"ed>I and as a result is una!le to "ass through %essels efficientl.

'ncorrect ?nswers

?nswer 2 Progressi%e sli""age of the "hsis though the h"ertro"hic one descri!es sli""ed

ca"ital femoral e"i"hsis.

?nswer , &hese radiogra"hs are most consistent with osteonecrosis of the femoral head.

&here is an increased incidence of 6almonella osteomelitis in "atient with 6ickle ;ell

disease> !ut 6ta"hlococcus aureus is still the most common organism.

?nswer * ?ccumulation of glcosaminoglcan !reakdown "roducts descri!es lsosomal

disorders.

?nswer 5 ;O35?1 or ;O35?2 mutation descri!es the mutation of 9hlers anlos

sndrome.

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21 ) (OBQ0.28) &he "arents of a wheelchair4!ound 84ear4old !o with cere!ral "als

 "resent with difficult during dia"er changes and with hgiene care. <is "hsical e+am

demonstrates 5R of hi" a!duction on the left hi" and 15R on the right. ?n ?P "el%is radiogra"h

is shown in figure ?. What is the most a""ro"riate treatment# $e%iew &o"ic 

'D$96 ?

Q' ,21

1. Bilateral !oto+ inAections and "hsical thera" 

1- (5/*C)

2.  :ighttime Pa%lik harness 

2- (8/*C)

,. Bilateral a!ductor release and %algus femoral osteotomies 

12- (5/*C)

*. Bilateral adductor release> %arus femoral osteotomies and aceta!ulo"lasties

5- (2*/*C)

5. O!ser%ation with re"eat radiogra"h in months

5- (10/*C)

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;hildren with s"astic cere!ral "als de%elo" hi" su!lu+ation as the result of long term muscle

im!alance. 6u!lu+ation can "rogress to hi" dislocation with resulting difficulties in seating>hgiene or "ersonal care> and/or hi" "ain. &he "atient has !ilateral dislocated/near dislocated

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hi"s with aceta!ular ds"lasia.

lnn and 7iller "ro%ide a thorough re%iew of hi" disorders in "atients with cere!ral "als

including etiolog> "hsical e+am and treatment guidelines. $ecommendations included hi"

reconstruction for children o%er * ears of age with se%ere su!lu+ation or dislocation if

se%ere degenerati%e changes are a!sent. <i" reconstruction consists of a one4stage soft4tissuelengthening with %arus derotational femoral osteotom and "ossi!le aceta!ulo"last.

6"iegel and lnn also ha%e "ro%ided a com"rehensi%e re%iew of hi" ds"lasia in "atients

with cere!ral "als. &he article discusses earl inter%ention to "re%ent com"lications

associated with su!se@uent hi" dislocations. 6urgical inter%ention in "atients older than *

ears with hi" dislocations was once again hi" reconstruction with soft4tissue lengthening>

femoral osteotomies and aceta!ulo"lasties in "atients in "atients with marked aceta!ular

a!normalities.